3 What is an M-SAA?Prior to providing funding for the provision of services to its local health system, the Local Health System Integration Act, 2006 requires that the LHIN and the Health Service Provider (HSP) enter into a service accountability agreement.The Multi-Sector Accountability Agreement (M-SAA) is a multi-year agreement.It supports a collaborative relationship between the LHIN and the HSP to improve the health of Ontarians through better access to high quality health services, to co-ordinate health care in local health systems and to manage the health system at the local level effectively and efficiently.The HSP and the LHIN agree that the provision of services to the local health system by the HSP will be funded as set out in this AgreementFor a Summary of Key Changes between Current and new M-SAA, see Appendix 1

6 LHIN/Sector ResponsibilitiesLHINs are responsible for:Training and supporting HSPs through the Community Annual Planning Submission (CAPS) and M-SAA processesNegotiating performance targets within the context of a provincial frameworkMonitoring the achievement of specific performance goals under the M-SAA and ongoing performance managementHSPs are responsible for:Ensuring their governance and operations support high quality carePromoting leading performance improvement approachesProviding access to high quality health services and coordinated health care in an effective and efficient mannerIdentifying integration opportunities and engaging the public and stakeholders in any planned service changes

8 M-SAA ApproachIn May 2013, the M-SAA Advisory Committee was established (Members of the Advisory committee include LHIN staff, Ministry staff, sector representatives and sector Association representation)In July 2013 the mandate and scope of authority of the Committee was established by the LHIN CEOs and was confirmed as follows:Work with LHIN Legal Services, identify opportunities to revise language that either requires updating or would benefit from greater clarityWork with community sector representatives, invite and review sector feedback (175 sector comments were received and individually addressed)Finalize a three year M-SAA by the end of 2013 to enable local execution by March 31, 2014.On December 17, 2013 the M-SAA Advisory Committee endorsed the M-SAA and SchedulesThe Committee will continued to meet throughout the life of the agreement to advance M-SAA related priority issues

9 M-SAA Development PrinciplesThe M-SAA Advisory Committee was guided by the following principles:The process is to be undertaken with a spirit of trust and collaboration among the province’s community HSPs, sector associations and the LHINs.The M-SAA will align with provincial health system priorities and be consistent with Ministry of Health and Long-Term Care (ministry) policy, legislation and regulations.The M-SAA will strive to streamline processes, minimize administrative burden and provide clarity for HSPs where possible.

11 CAPS ApproachThe Community Accountability Planning Submission (CAPS) is a three- year planning document that facilitates the negotiation of the M-SAAs between the LHIN and each HSP.In the absence of definitive funding targets, CAPS will be based on a planning assumption of 0% base adjustment. CAPS should be prepared to maintain service levels within the 0% planning assumptionThe M-SAA Schedules will be refreshed in the fall of each year of the agreement to confirm the current year’s planning assumption and to update the agreement’s performance and explanatory indicatorsThe provincial due date for the submission of a HSP Board approved CAPS was November 15, 2013.

12 HNHB LHIN Engagement StrategyAug 30-Sept 9, 2013: HSPs from the HNHB LHIN were asked to assist in testing of the CAPS file.Sept 10-15, 2013: HSPs were asked to contribute input into new Part A of the CAPS (Narrative) as well as feedback on past CAPS Narrative.Oct 1, 2013: HNHB and Province launches CAPS educational material including. Orientation presentation (taped), User Guide, Reference Manual.Oct 1-4, 2013: HNHB HSPs were invited to submit questions to the LHIN regarding CAPS Part A and B and on all educational material.Oct 3, 2013: HNHB holds HSP Question and Answer teleconference with LHIN Financial, Quality and Risk Management, Health System Transformation and Access to Care staff in attendance.

13 HNHB LHIN Engagement Strategy continued.Oct 4 - Oct 10, 2013: General CAPS questions were sent to HNHB LHIN lead and response have been provided. Specific questions were directed to review teams.Oct 10, 2013: Provincial FAQ document is distributed to all HSPs throughout the province. Approximately 38 questions were received from across all LHIN engagement sessions between Oct 1-4, 2013.The HNHB LHIN also offered each agency in our LHIN an opportunity to meet with the LHIN staff face to face, or by telephone to discuss their CAPS prior to submitting their CAPS on Nov 15, 2013.

14 2014-17 HNHB CAPS Reporting Compliance%CAPS Submission on Time (due date November 2013)98%CAPS Complete/ accurate Data at time of submission11%Board Approval Received On Time (due date November 15, 2013)77%Submission of No Deficit100%Source: Internal Reporting and MonitoringResults based on 96 CAPS Submission

16 Performance IndicatorsIn April 2010, the LHIN-led Health System Indicators Initiative (HSII) was established to create a coordinated, system-based approach to indicator identification, development, maintenance and reporting.Central to the mandate of HSII is the close collaboration with provincial and national partners in order to leverage their organizational expertise related to indicator development, benchmarking, data extraction, and analysis.In September 2013 a revised mandate provided a greater focus on alignment to system priorities, advancing system performance improvement through the SAAs and other mechanisms, and enabling monitoring and reporting.

17 M-SAA Indicator Work Group Focus and ApproachTo review current indicators and develop recommendations to reduce the number of indicatorsTo develop recommendations regarding the definition and target setting approach for the administrative indicator calculationTo align existing indicators with pan-LHIN imperatives

18 Performance Indicators (Schedule E)The Performance Schedule E in the M-SAA contains the following two indicator sections:Pan-LHIN Indicators: Core indicators that are relevant to all LHINs and all community sector HSPs and Sector-Specific indicators that are only relevant to a specified sector.Performance Indicators are measures of HSP performance for which a Performance Target is set; Technical specifications of specificExplanatory Indicators are measures of HSP performance for which no Performance Target is set. Technical specifications of specific.Performance and Explanatory Indicator descriptions can be found in the “M-SAA Indicator Technical Specifications” document. On the HNHB LHIN website MSAA Indicator Tech Specs2. LHIN-Specific Performance Obligations: Each LHIN may add specific performance objectives and obligations for their HSPs. LHINs are committed to minimizing any undue burden placed on providers with respect to performance management by focusing on a limited number of indicators aligned with local priorities.Performance Indicators (Schedule E)

20 Community Care Access Centres Sector Performance IndicatorsAccess: Wait time 1. From Hospital Discharge to Service Initiation (Hospital Clients)Access: 90th Wait time 2. 90th percentile Wait time from Community Setting to Community Home Care ServicesPercentage people registered with Health Care Connect who are referred (Retired)Details:Reporting obligations are already in place with the ministry

21 Community Support Services Sector Performance IndicatorThere are no Performance Indicators for in the M-SAA for the Community Support Services sector.

23 Community Mental Health and Addiction Sector Performance IndicatorsThere are no Performance Indicators for the Mental Health and Addiction sector in

24 HNHB LHIN-Specific Performance Indicators and Reporting ObligationsCommunity Support Services (CSS) and Community Mental Health and Addiction (CMH&A):Quality Obligation:“CSS and CMH&A organizations will work with the HNHB LHIN to develop and have in place the following three components of the quality plan: 1) Board approved policy on quality; 2) Balanced scorecard; and, 3) A Quality Plan to track variances and outline strategies for improvement. The CSS and CMH&A will align quality strategies with the LHIN-wide Quality Plan as set out by the Quality Guidance Council. This will be submitted to the HNHB LHIN at the end of each fiscal year ( , and )”

25 HNHB LHIN-Specific Performance Indicators and Reporting ObligationsCommunity Health Centres and CCAC:Quality Obligation:“The [CHC/CCAC ] will work to develop a Quality Improvement Plan (QIP) with guidance from the Health Quality Ontario (HQO) quality framework and templates for submission by the [CHC/CCAC] to HQO on or before fiscal year end. The QIP will inform HQO’s review and feedback of the broader [CHC/CCAC] sector alignment with its quality framework. The [CHC/CCAC ] will also align its quality strategies with the LHIN-wide Quality Plan set out by the Quality Guidance Council and provide the HNHB LHIN with a copy of their QIP to HQO”% of clients registered with CHC diagnosed with diabetes who have had a foot exam within the last 12 months

26 HNHB LHIN-Specific Performance Indicators and Reporting ObligationsAll Providers:Behavioral Supports Ontario (BSO) Obligation:LHIN providers were identified in as either an Integrated Community Lead (ICL) agency or a Participating BSO ICL Contributing agency.All agencies are expected to continue their roles inEach agency should refer to the HNHB LHIN’s website for information on the responsibilities of their agency.BSO HNHB LHIN Site

27 Performance StandardsAll performance indicators have an associated target and standard of performance. Variance outside of the standard triggers a performance management processes.To complete the targets and standards for the performance indicators, the following principles will be employed:Where provincial targets and corridors exist, the LHINs and HSPs will take these into consideration.Where appropriate, use past experience from M-SAA and MLPA indicators.Incorporate analyses of historical variation to inform corridor recommendations.Use % range for financial and volume indicators.

28 Proportion of Budget Spent on AdministrationThe Proportion of Budget Spent on Administration indicator measures how much an organization spends on administrative services relative to total operating expenditures.The HNHB LHIN’s expectation is that a shifting of resources away from administration will:increase capacity to deliver services directly impacting client carecontribute to the sustainability of the local health system.In the HNHB LHIN asked each HSP to review their functional center allocations and provided education to the HSP’s on how to calculate this indicator.The LHIN has completed its CAPS review of the change in this indicator target from toNext steps include further engagement with HSP’s to determine the reasons why some HSPs still have high targets.

29 Performance ManagementHow the LHIN chooses to deal with an indicator outside the standard depends on a number of factors, including:What is the realized and/or potential impact on the clients served?Is this the first blip on an otherwise clean performance record?Is this a unique event and unlikely to recur?Are other areas of the organization or other HSPs affected?What is the LHIN’s confidence in the HSP’s ability to manage performance going ahead?Depending on the above, the LHIN could choose to start with a less formal tact. The formal process is always available...and can be triggered at any point.

31 Next Steps and Important DatesThe LHINs will work collaboratively with their HSPs to implement M-SAAs by March 31, 2014HSP Education Session…………………………………………….January 15, 2014Local Indicator target setting engagement…...Dec. 16, 2013 to January 15, 2014M-SAAs sent to 96 HSPs………………………………………….January 31, 201496 HSPs signed M-SAAs returned to HNHB LHIN…………………March 1, 2014M-SAAs take affect………………………………………….…April 1, 2014

32 A copy of this slide deck will be available on the HNHB LHIN website at the following location: M-SAA HNHB Presentation Questions may be sent to the HNHB LHIN until January 31, 2014 to:

44 Appendix 3: Core (All Sectors) Explanatory IndicatorsCost per individual serviced by program/service/functional centreCost per unit of service by functional centreClient experience (New Category)Details:Client Experience was an explanatory indicator for the Mental Health and Addiction sector only inIndicators Work Group identified need to enhance linkage with quality and patient experience for all sectors

45 Appendix 3: Community Care Access Centres Explanatory IndicatorsAccess: Wait time 1. From hospital discharge to service initiation (hospital clients) by population groups (short stay, short stay rehab, long-stay complex)Access: Wait time 2. 90th percentile wait time from Community setting to community home care services by population groups (short stay acute, short stay rehab, long-stay complex)Average monthly cost per episode (adult short stay, adult long-stay complex, end of life, children medically fragile)

46 Appendix 3: Community Care Access Centres New Explanatory IndicatorsClients with MAPLe scores high and very high living in the community supported by CCACClients placed in LTCH with MAPLe scores high and very high as a proportion of total clients placedDetails:Moved from CCAC performance indicator categoryIndicators fit this category and provide valuable information about how the system is functioning and the opportunities for changeIndicators are not a good measure for performance as targets are set locally by each LHIN

47 Appendix 3: Community Care Access Centres Developmental IndicatorsPercentage of clients with a new or existing pressure ulcer that failed to improve (Retired)Medication safety (Retired)Percentage of home care clients who say they have fallen in the last 90 days (Retired)DetailsIndicators retired as developmentalIndicators were not identified by HQO on the Common Quality Agenda

48 Appendix 3: Community Support Services Explanatory IndicatorNumber of persons waiting for service (by functional centre)

49 Appendix 3: Community Support Services Developmental IndicatorsAverage number of days waited for first service (by functional centre) (New Category)Details:Moved from CSS Explanatory indicator category as the data is not yet availableMove to explanatory in years 2 or 3Repeat unscheduled emergency visits within 30 days for mental health conditions (Retired)Repeat unscheduled emergency visits within 30 days for substance abuse conditions (Retired)Indicators are difficult to measure as cannot follow clients between the hospital and the community

51 Appendix 3: Community Health Centres Explanatory Indicators continuedNumber of registered clients (New)Specialized care (New)Supervision of students (New)Third next available appointment (New)Non-insured clients (New)Repeat unscheduled emergency visits within 30 days for mental health conditions (Retired)Repeat unscheduled emergency visits within 30 days for substance abuse conditions (Retired)Details:Data is a challenge as the cell size is small

53 Appendix 3: Community Mental Health and Addiction Explanatory IndicatorsNumber of days waited from referral/application to initial assessment completeAverage number of days waited from initial assessment complete to service initiationRepeat unscheduled emergency visits within 30 days for mental health conditions (New Category)Repeat unscheduled emergency visits within 30 days for substance abuse conditions (New Category)Details: both of the 2 indicators above were moved to Explanatory indicator inClient experience (Retired)Details: Moved to Core indicator

55 Appendix 4: M-SAA Content - ArticlesArticle 1 Definitions and Interpretation Clarifies terminology used throughout the document. Article 2 Term and Nature of the Agreement Defines the term of the service accountability agreement as April 1, 2014 to March 31, Article 3 Provision of Services Describes how services will be provided in accordance with legislation, applicable policies, e-health/IT compliance and the terms of this agreement. Discusses subcontracting services and conflict of interest. Article 4 Funding Outlines conditions of funding, payment and provision limitations. Procurement and disposition of goods and services are also described. Article 5 Repayment and Recovery of Funding Defines circumstances under which funding may be adjusted and/or recovered.

56 Appendix 4: M-SAA Content - Articles continuedArticle 6 Planning and IntegrationDiscusses multi-year planning CAPS requirements in alignment with LHIN IHSP and priorities.Article 7 PerformanceDiscusses the need for ongoing performance improvement and the mitigating process in the event of performance factors (non-performance).Article 8 Reporting, Accounting and ReviewDescribes the obligations of reporting and record maintenance, French language requirements, disclosure of information, transparency and reviews.Article 9 Acknowledgement of LHIN SupportHSP publications are required to note LHIN support, be approved by the LHIN, and indicate views do not necessarily reflect those of the LHIN or Government.Article 10 Representations, Warranties and CovenantsConfirms the HSP’s ability to enter into the agreement and carry out the funded services with the appropriate governance, personnel and documentation.

57 Appendix 4: M-SAA Content - Articles continuedArticle 11 Limitation of Liability, Indemnity and InsuranceOutlines the limitation of liability and indemnification for the LHINs and the required insurance provisions for the HSP.Article 12 Termination of AgreementDescribes the parameters for termination of the agreement by the LHIN and by the HSP.Article 13 NoticeDetails how notices to a party must be provided.Article 14 Additional ProvisionsIdentifies additional provisions to the agreement.Article 15 Entire AgreementDefines the agreement as constituting the entire agreement, superseding all prior agreements.

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